Overall, as shown in Table 2.3, the AMR partnership facilitated the strengthening of higher education institutions and health systems in Mozambique and Malawi, enhancing academics’ research and profes-sional skills, generating knowledge to inform best practices in AMR containment, and, to some extent, increasing the participation of women in science.
With respect to the latter two areas, knowledge generation is emer-gent, as is evident from the range of postgraduate research topics, and from the results of the national situational analyses of AMR and national AMR research priority setting. The research priority-setting exercise yielded 16 research -domain clusters with 108 topics in Malawi, and 20 research-domain clusters with 76 topics in Mozambique. The research clusters were similar for both countries, spanning areas such as: laboratory studies, sources of supply, environmental reservoirs, animals and agriculture, AMR in specific diseases, the burden of AMR, health-worker competencies, community practices, policy and legisla-tion and indigenous knowledge. Research topics covered by the first cohort of master’s and PhD students aligned both with these clusters and with global AMR research priorities. Topics included: the epidemi-ology of AMR in hospitals and the community; the prevalence of AMR in the food chain; studies of antibiotic use, supply and expenditure; and knowledge and attitudes related to antibiotics and AMR among stu-dents, healthcare workers and patients.
Globally, more women are pursuing careers in the health sciences but a gender gap remains visible, expanding at PhD level and peaking at postdoctoral level, with women constituting only 28.4 per cent of the world’s scientists working in research and development in 2013 (Unesco 2015). In the partnership, Norway ranks highest (6th) on the gender equality index for 188 countries, followed by South Africa (90th),
Table 2.3 Project outcomes and illustrative gains for Malawi and Mozambique
Master’s in Health Sciences (online programme) approved by relevant authorities
E-teaching and learning platforms installed and IT personnel trained Developed and introduced the
first Master’s in Health Sciences (Research) with an AMR focus; 14 students from health, agriculture
Ongoing training in research proposal development, data analysis, scientific writing, and research supervision
Staff development Exchanges of technical staff, faculty and students in various areas, including molecular epidemiological laboratory work, online teaching pedagogies, IT, qualitative data analysis
10 faculty members, 70 per cent of whom are women, are undertaking postgraduate study with an AMR focus
8 faculty members, 37 per cent of whom are women, are
National situational analysis on AMR was conducted using the One Health approach in partnership with government ministries (health, education, agriculture and veterinary services) professional councils and associations, and a report was submitted to the Ministry of Health National consensus was reached on priority research areas for the optimal management of infections in the context of antimicrobial stewardship and conservancy. This was developed across sectors including health, veterinary medicine, and agriculture/environment Increased in project leadership roles and in postgraduate programmes, but overall women constitute only 36 per cent (21 out of 58) of project participants in 2016.
Participation of women
significantly improved, especially with respect to project leadership, with women constituting 89 per cent (28 out of 53) of project participants in 2016.
Mozambique (139th) and Malawi (145th) (UNDP 2016). Noting that women are disproportionately under-represented in certain areas of health services and education (among physicians and faculty, for
example) and over-represented in others (such as nursing), a concerted effort was made to ensure at least 50 per cent of project participants at master’s and PhD level were female. Overall, the participation of women in the project improved from 34 per cent in 2014 to approximately 43 per cent in 2015 and to 60 per cent in 2016. Mozambique, in particular, made great strides in gender equity, with women constituting 89 per cent (28 out of 53) of project participants in 2016.
Sustainability
In the context of this project, we defined sustainability as the continu-ation of the project goals, principles and efforts to achieve desired outcomes. As the project period ended, it was clear that the project was well-established. The project team therefore assessed the programme in relation to its initial goals and planned for the future. A summary of this assessment is provided below
At UNIMA’s College of Medicine
The antimicrobial stewardship programme at the College of Medicine, UNIMA is likely to be sustained for several reasons. Firstly, there is a very strong buy-in from the institution’s top management because of the close alignment of the project activities with the College’s develop-ment plan. Senior leaders in the College willingly support the activities of the project and, through regular monitoring, ensure that the team delivers in the interests of the institution and the project.
Secondly, project stewardship processes and structures have been systematically embedded within the College structure, assuring their continuation beyond the funding period. For instance, the project’s PI is also deputy dean of the Faculty of Biomedical Sciences, while the co-PI who is responsible for overseeing education and research is also dean of postgraduate studies and research. Having people in such key positions in the College increased awareness of the project within and beyond the College and improved project implementation.
Thirdly, the programme is pioneering the introduction of online teaching in the College. This aligns with the institution’s long-term
vision and strategic development plan, which means the College will continue supporting the project after the funding period lapses.
Fourthly, the project involved key national stakeholders, including the Ministry of Health, which sees antimicrobial stewardship as a pri-ority area. Reasons for this include the fact that Malawi is listed among the world’s least developed countries, and drug resources in most of the country’s health facilities are extremely limited. This makes AMR an even bigger threat here than it is in more prosperous countries. In addition, the health ministry and mission hospitals support the project because it ensured that their staff received much-needed training and their reference laboratory infrastructure and equipment was upgraded.
Ongoing collaboration between the health ministry and the project is crucial for project sustainability. Already, the health ministry has ena-bled key staff members to join the postgraduate programme and has taken responsibility for supporting the reference laboratory. Through their membership of the project’s national steering committee, senior members of the ministry helped shape the direction of the project, and were kept informed of project activities to ensure the alignment of the project with the interests of the ministry and the university.
Finally, the project has a working understanding of, and good rela-tionships with, other projects in the College. For example, the Africa Centre of Excellence in Public Health and Herbal Medicine, which has indicated a willingness to fund students with limited resources who wish to pursue the MSc offered by the project. This intra-project good-will ensures that sufficient numbers of students enrol in the programme each year, thus helping to ensure the sustainability of the project.
At ISCISA
Five key factors support the sustainability of the AMR stewardship programme at ISCISA. Firstly, the ministries of health, agriculture and the environment, as well as GARP-Mozambique, see AMR as a top pri-ority in their respective action plans. ISCISA formulated and reached collaborative agreements with these partners, to address AMR using the One Health approach within the project context. Secondly, through the project, the abovementioned multisectoral group developed and
finalised the country’s National Action Plan, operationalising the coun-try’s commitment to containing AMR and preserving antibiotics.
Thirdly, the new reference laboratory increases not only the health system’s capacity but also the capacities of the ministries of agriculture and the environment with regard to AST for AMR containment. The health ministry has undertaken to ensure a continuous supply of rea-gents and the maintenance of equipment in the laboratory. Fourthly, the solid South–South–North bonds established during this project set the foundation for ongoing collaboration and technology transfer.
Finally, as noted, ISCISA launched its first ever master’s programme in 2016, in the area of antimicrobial stewardship and conservancy. Over time, this programme will help create the critical mass of health work-ers that the country needs to address this public health threat.
Conclusion
To sum up, the project facilitated compliance with national, regional, and international commitments, advanced the mobilisation of formal collaborations between government ministries around the common goal of AMR containment, and generated knowledge from research to inform country-specific policy and practice using the One Health approach.
Although the project exceeded its objectives in several ways, it also faced substantive, albeit not insurmountable, challenges. The main challenges included finding ways to address the intractable issue of gender inequality, some over-reliance on UKZN and the UiT partners and hesitancy from UNIMA and ISCISA to assume full ownership of the project in the penultimate project year as had been planned.
The project continues to tackle gender inequality through the tar-geted recruitment of women to its postgraduate programmes, through outreach programmes targeting schools that encourage girl children to choose science subjects, and through participating in national discus-sion forums on gender equality. In terms of project ownership, joint sustainability planning exercises, drawing on the principles of mutual benefit and symmetrical engagement, cleared the path for the transfer of powers and responsibilities.
Key to the project’s successes were the fact that this South–South–
North partnership was committed to national capacity building that would address the global AMR challenge. In addition, we had a strong Southern institutional partner with long-term experience in address-ing the specific challenges related to African health and higher education, and a well-resourced Northern partner committed to shar-ing its theoretical and practical knowledge and experience in AMR and to supporting the Southern institutions to adapt this knowledge to their local context. Importantly, anchoring the project leadership at high institutional level, and recruiting key representatives from the ministries of health and education on to the steering committee, were imperative for creating local ownership and sustainability. Collectively, all partners contributed to the development of national capacity in AMR in the South through the training of high-calibre graduates at master’s and PhD level who will continue to generate and disseminate local evidence for reducing AMR, train local clinicians in AMR steward-ship practices and be prepared to take on leadersteward-ship positions in academic and government health and laboratory services.